Note: When completing this form on your computer, you must tab out of the fields to complete the entry.
Otherwise, the field will not print properly.
EMPLOYEE I.D. NO.
PERSONAL DATA FORM
Check Box
If Name
Change
DATE
MO
UPAY 544-3 (R-7/87)
TYPE OF ACTION (check appropriate box)
EMPLOYMENT complete all information
DY
CAMPUS
APPOINTMENT
DAVIS
ACAD.
MGMT.
DATA CHANGE complete information to be changed (if name or address,
complete Box 1).
HOME DEPARTMENT NAME
TERMINATION complete permanent address
WORK DEPARTMENT (if different from above)
EMPLOYEE NAME (LAST, FIRST, MIDDLE INITIAL)
SUFFIX
YR
STAFF
PRIOR NAME
P1
(1-2)
A. ADDRESS INFORMATION
PERMANENT ADDRESS
P2
(1-2)
LINE 1
P3
(1-2)
LINE 2
Your name as you wish it to appear on your ID badge
CAMPUS PHONE 1
CITY
STATE
ZIP CODE
FOREIGN
UC DIRECTORY
P4
(1-2)
HOME PHONE
CAMPUS PHONE 2
DISCLOSURE OF INFORMATION (See Reverse)
Check box for
EMPLOYEE ORGANIZATIONS
information you DO
NOT want listed
SPOUSE’S NAME
PERMANENT
ADDRESS
P5
(1-2)
HOME PHONE
NUMBER
1
SPOUSE’S
NAME
1
1
DO YOU WANT YOUR
HOME ADDRESS
RELEASED TO
EMPLOYEE
ORGANIZATIONS?
YES
NO
1
B. EMERGENCY DATA
PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
PA NAME
(1-2)
PB
(1-2)
STREET ADDRESS
PC
(1-2)
CITY
RELATIONSHIP
PHONE 1
STATE
C. STUDENT STATUS
Deg. Cand.
Not Reg.
1
PHONE 2
D. EDUCATION
UC STUDENT STATUS
Not Reg.
ZIP CODE
Units this
Qtr.
Undergrad
2
Grad
3
MARK HIGHEST DEGREE ONLY
No. Acad.
Cert.
4
H.S. or
Equiv.
YEAR AWARDED
Trade Cert.
Assoc.
N
H
T
UNIVERSITY ATTENDED & LOCATION
Bach.
A
Mast.
B
Prof.
M
P
Doct.
D
FIELD OF STUDY
E. PERSONAL INFORMATION AND CITIZENSHIP STATUS
SEX
U.S. CITIZEN?
MALE
FEMALE
M
YES
VISA
STATUS
VISA EXPIRATION
DATE
Date entered United
States
Intended length of stay
Country of residency
NO
MO
F
DY
YR MO
DY
F. PRIOR EMPLOYMENT ( other than UC or State)
YR
G. RELATIVES EMPLOYED AT UC?
EMPLOYER NAME
EMPLOYED
FROM
MO
TO
YR
MO
NO
YES
INDICATE: NAME, RELATIONSHIP, &
DEPARTMENT
YR
H. PRIOR OR CONCURRENT UC/STATE EMPLOYMENT ( include DOE Labs)
EMPLOYED
FROM
TO
MO
YR
FICA
YES
NO
If name different than above – enter below
CAMPUS
DEPARTMENT
RETIREMENT
SYSTEM
If relative is employed in the same unit, is
approval on file?
YES
NO
MO YR
I. LANGUAGES – INTERPRETER INFORMATION
FOREIGN LANGUAGES YOU:
SPEAK
READ
WRITE
SPEAK
READ
WRITE
SPEAK
READ
PF
(1-2)
LICENSE (NUMBER)
ACCOUNTING USE ONLY
Visa Exp
Date of
Country
Date
U.S. Entry
Code
ACCOUNTING USE ONLY
Student
Highest
P8
Status
Degree
(1-2)
D001-1 (2/90)
SPEAK
EMPLOYEE SIGNATURE
J. LICENSE
PE
(1-2)
WRITE
Year
Awarded
type
code
Work Dept
Code
Sex
Hire/Rehire
Type
Cit
READ
WRITE
DATE
EXPIRATION DATE
MO
DY
YR
PERSONNEL
Prior State
Language
Service Mos
#1
Visa
#2
#3
#4
Univ Att
Code
ACADEMIC AFFAIRS
Field of
Prio Univ
Study Code
Empl Code
PERSONNEL
Prior Serv
Prior Serv
Cd
Mos
RETN: Accounting – 1 year after modification
Other Copies – 0-5 years after modification